GW1-2021-01336_Well Construction - GW1_20210329

For Internal Use on]
1,Well Conn-actoritlforma6on:
Chris Morgan
R'ell Commctor Nome 14.WATERZONES
FROni TO DPSCRIMON
3572 '1 t -)l R.
NC Nell Contractor Certification Number fL ft.
Morgan Well & Pump, Inc, iS.OUTER CASING formWHeased ivclls OR LtNER Iirrbly)
17ROM TO DL1,11ETER THIC[INFSS niATER1AL
Cumpany Nome -1 ft. � ft. 61/8 in
�.1 c►c�f3 sd2i paz
2.Well Construction Permit � VJ a b I6.IICNERCAS(NGORTU ING( eothermal closed-too
List all aapll"I'le a'.. r --,pennar ft.a U1C,Couugr.Stale.{'arimrce,etc) PRO%I ft TO DIAn1El'ER THICIW r55 nLiTER1AL
fit. Ih
3.Well Use(checl:well use):
fit• fL In.
Water Supply Well: 37.SCREEN -
Arculturdl DMuninipel/Public rROnf To DuniETER SLOT SIZE THICIN'FSs nL%TE tAL
Geothermal(ficuting/COOlin Supply) ft
g PP Y) QlResidendel Water Supply(single)
Industrial/Commercial Ft
QlResidential Water Supply(shared)anon III.GROUT
Non-Water Supply Well: FROM TO aTATERIAL EMPLACEMEn-rnlLTuOD&Antoun'T
Monitoring L 0 a. as ft. bentonile poured
Injection Well: QlRecovcry fL
ft.
_ �AquiferRecharge GroundwaterRemediation rt• rr.
Aquifer Storage and Recovery QlSaliniry Barrier t9-SAND/G12AVEL PAC[{tfa Heabtc)
Aquifer Test FRO11 TO M1fATERfAi Ent
Experimental Technology PraCFllrEhT aiETHOD
QlStormwater Drainage ft. ft,
QSubsidence Control
Geothermal(Closed Loop) ITmcer ft. ft
20.DRILLING LOG(athch adaiaoaal sheets H aems'arv)
Grothcmial(He adng/Cooling Return) Other(explain under;21 Remarks) ERoni TO DESCRII•nox anon nardaox saiumckn as mslra ere.)
Cj fit, t� R,4 •ram
.Dace YVell(s)Cnmptc[ed•�_�2--t l D- �
Well[D;S `
n/a r
l s It. G ft.
5a.Well Location: r^o t"1 �1oe�t.
p ft. 6 6 Et.
�U/hm y /�'TC�4,tcy SS n/a 6fL
acdiry/��}V pia FocilityrD.(ifapplinble) ft. fit.
8C)09 'TQMPQS L G✓axl� rI. ft.
Gr
Physical Address.City.and Zip 7 fit. ft.
U l�:6ti IM06 22S3S7 a-1-REMARKS
CDunry fecal ldcniifirdsion No.(plN) v�H
5b.Latitude and longitude In degrees/minutes/seconds or decimal dogreos:
(ifwell field,one Winne is sufficient)
3 Y.qR 3 r 4S' N _ 90. $11117 z2.Certification:
W
G.Is(are)tlte wells) ): Permanent or DTemporary siIInmaro.1 Ccruf6d Well Contractor Dam
a'
7.Is this a repair to an esistaga ,� By signing this lb a..•I hereby cerr f,tlmt Iba ant/ J tvat te'erel ccontrolled in accm'dalree P e wall: Dyes or n)No nilh I5A A'CiC 02C.0100 or 15..1 NCAC 02C.0200 Well Con.nnrctian Standard..,mu1 dim a
/fthu h,a repair,fill our knot well construction infonnotfaa and ecplain Iae nature ofihe copy ofthic recordbas been,pmeidedlu Ibc teen nurser.repair under ail remarks section ormt lite back oflbts ram _
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well cumslmction,only 1 Gr-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional°ages if necessary.
drilled: ' `
g s SUBIMTTAL INS T RUCTIONS
9.Totni well depth below land surface: `list all dep (fi) 24°. F'or All Wells: Submit this font within 30 days of completion of well
For nndtiplc nvNt tlrs lfdderenr(ernmpfe-3 tCa200"anA r 2Lai100� y p
�I(7 construction to the following:
lfnvmr fete!is abnre cvsing,use 10.Static water)eves helmv tap of Casing: .) Division of Water Resources,Information Processing Unit,
"+"
1617 it4ail Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: rotary above,also submit one copy of this farm within 30 days of completion of well
(i.e.auger,rotary,cable,direct posh,etc.) construction to the following:
FOR WATER SUPPLY v'4'ELLS OPILY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a C� Method of test air pressure 24e For Water Suotiiv E Infection Wells: In addition to sending the form to
fanular the address(es) above, also submit one copy of this forth within 30 days of
I3b.Disinfection type: 9 Amount: 1 6 Z. completion of well construction to the county health department of the county
wherz constructed.
Fowl Gw-1 North Carolina Department of Encinoamenud Quality-Division of water Rctoamcn _�
Revised_v-2�-._016